Thank you for completing the caregiver career application at Health Force of Georgia. There are 10 sections to the Licensed Nursing Personnel Application form. Be sure to complete ALL sections before clicking submit. The form will prompt you if there is required information missing in any section. Fields marked with a red * are required.

Licensed Nursing Personnel Application

1. General Info

Date of Application*

Nursing Certification*

RN

LPN

CNA

MA

PCA

Name*

FirstMiddle InitialLast

Physical Address*

Street AddressApt.#CityStateZip Code

Email Address*

Enter EmailConfirm Email

Phone*

End General

2. Emergency Contact

Emergency Contact*

FirstLast

Emergency Contact Phone*

End Emergency Contact

3. Requested Information

Are you at least 18 years old?*

Yes

No

Will you work in a home with a pet?*

Yes

No

Do you have access to public transportation?*

Yes

No

Do you have access to a car?*

Yes

No

Do you have a driver’s license?*

Yes

No

Driver License Number*

Driver's License State

Driver License Expiration Date*

I am fluent in the following languages

List languages.

What are your work preferences?

List when you are available for work.

What days/hours are you NOT available to work?

List when you are NOT available for work.

How did you learn of job opportunities at Health Force of Georgia?

Online Search

Professional Colleague

Friend

Other

End Requested Information

4. Criminal Background

Have you been convicted of a crime other than a traffic violation within the last 7 years?*

Yes

No

If Yes, please explain.

Note: Conviction will not necessarily disqualify an applicant from employment.

End Criminal Background

5. Professional Liability Insurance

Do you have professional liability insurance?*

Yes

No

If Yes, who is the insurance carrier?

What is the amount of insurance coverage?

Have you ever been bonded?*

Yes

No

End Professional Liability Insurance

6. Skills Inventory

Tell us about your expeience. Check areas in which you are proficient.

Skills Inventory Checklist A

Head Nurse

Experience

Training

Home Care

Experience

Training

Staff Relief

Experience

Training

Private Duty

Experience

Training

Hospital

Experience

Training

Nursing Home

Experience

Training

Industrial Nurse

Experience

Training

Public Health Nurse

Experience

Training

School

Experience

Training

Geriatrics

Experience

Training

Orthopedics

Experience

Training

Peds-ICU

Experience

Training

OB/GYN

Experience

Training

Neonatal-ICU

Experience

Training

Med-Surg

Experience

Training

ICU-CCU

Experience

Training

IV Therapy

Experience

Training

Psychiatric

Experience

Training

Oncology

Experience

Training

Neurology

Experience

Training

Other. Please explain.

Skills Inventory Checklist B

Meds

IV

PO

IM

Ztrack

Interdermal

Sub Q

Heparin Lock

Subclavian

Dressings, Sterile

Yes

Catheterization

Male

Female

Apnea Monitor

Yes

Cardiac Monitor

Yes

Fetal Monitor

Yes

EKG

Yes

Kangaroo Pump

Yes

Gastro Tube Feed

Yes

Suctioning

Yes

Trach Care

Yes

Respirators

Yes

Respiratory Therapy

Yes

MA-1

Yes

IPPB

Yes

IV Pump

Yes

Ostomy Care

Yes

Hyperalimentation

Yes

Oxygen Therapy

Yes

Other. Please explain.

End Skills Inventory & Education

7. Education

Tell us about your education.

High School Name

High School City & State

Graduated?

Yes

No

College Name

College City & State

Degree or Major

Graduated?

Yes

No

Other School or Institution Name

Other School or Institution City & State

Degree or Major

Graduated?

Yes

No

End Education

8. Employment History

List your last three employers starting with your most recent position. (Please list both permanent and temporary jobs.)

Employer One Info

Name of Employer One

Start Date - Employer One

End Date - Employer One

Employer One Address

Street AddressAddress Line 2CityStateZIP Code

Employer One Phone

Supervisor Name at Employer One

Position at Employer One

Salary at Employer One

Reason for Leaving Employer One

Type a brief description of why you are not longer working for this employer.

Employer Two Info

Name of Employer Two

Start Date - Employer Two

End Date - Employer Two

Employer Two Address

Street AddressAddress Line 2CityStateZIP Code

Employer Two Phone

Supervisor Name at Employer Two

Position at Employer Two

Salary at Employer Two

Reason for Leaving Employer Two

Type a brief description of why you are no longer working for this employer.

Employer Three Info

Name of Employer Three

Start Date - Employer Two

End Date - Employer Three

Employer Three Address

Street AddressAddress Line 2CityStateZIP Code

Employer Three Phone

Supervisor Name at Employer Three

Position at Employer Three

Salary at Employer Three

Reason for Leaving Employer Three

Type a brief description of why you are no longer working for this employer.

End Employer Info

9. References

List three references (Please no family members.)

Reference One

Name Reference One

FirstLast

Address Reference One

Street AddressAddress Line 2CityStateZIP Code

Phone Reference One

Occupation of Reference One

Reference Two

Name Reference Two

FirstLast

Address Reference Two

Street AddressAddress Line 2CityStateZIP Code

Phone Reference Two

Occupation of Reference Two

Reference Three

Name Reference Three

FirstLast

Address Reference Three

Street AddressAddress Line 2CityStateZIP Code

Phone Reference Three

Occupation of Reference Three

End References

10. Oath of Honor

Capability Statement*

Are you capable of performing in a reasonable manner the activities involved in the job or occupation for which you have applied? A description of the activities involved in such a job is attached. Do not answer this question unless you have been informed about the requirement of the job for which you are applying.

Yes

No

Oath*

I certify that answers given herein are true and complete to the best of my knowledge.
I understand that, in the event of employment, false or misleading information given in my application or interview may result in discharge.
I authorize investigation of all references and statements contained in the application for employment as may be necessary in arriving at an employment decision.
I understand that after meeting all other job prerequisites, and after I am offered a job, employment will be contingent upon the satisfactory outcome of a medical examination.
I understand that if I am offered employment, I will be working for Health Force of Georgia, on its payroll, at its client’s premises.
I understand that my employment may be terminated by Health Force of Georgia at any time, without liability to me for wages and salary except as have been earned by me at the date of such termination.
Information provided in my electronic employment application is true and accurate.
Clicking submit serves as my electronic signature.